Diagnostic Oral Glucose Tolerance Test Research Articles

GIP receptor antagonism eliminates paradoxical growth hormone secretion in some patients with acromegaly.

About 30% of patients with active acromegaly experience paradoxically increased growth hormone (GH) secretion during the diagnostic oral glucose tolerance test (OGTT). Endogenous glucose-dependent insulinotropic polypeptide (GIP) is implicated in this paradoxical secretion. We used the GIP receptor (GIPR) antagonist GIP(3-30)NH2 to test the hypothesis that GIP mediates this paradoxical response when GIPR is abundantly expressed in somatotropinomas. 25 treatment-naïve patients with acromegaly were enrolled. Each patient underwent one OGTT during simultaneous placebo infusion and one OGTT during a GIP(3-30)NH2 infusion. Blood samples were drawn at baseline and regularly after infusions to measure GH. We assessed pituitary adenoma size by magnetic resonance imaging and GIPR expression by immunohistochemistry on resected somatotropinomas. For mechanistic confirmation, we applied in vitro and ex vivo approaches. The effect of GIP(3-30)NH2 on paradoxical GH secretion during OGTT as a measure of GIP involvement. In four of seven patients with paradoxical GH secretion, GIP(3-30)NH2 infusion completely abolished the paradoxical response (P = 0.0003). Somatotrophs were available from three of four of these patients, all showing abundant GIPR expression. Adenoma size did not differ between patients with and without paradoxical GH secretion. Of 25 patients with acromegaly, seven had paradoxical GH secretion during OGTT, and pharmaceutical GIPR blockade abolished this secretion in four. Corresponding somatotroph adenomas abundantly expressed GIPR, suggesting a therapeutic target in this subpopulation of patients. In vitro and ex vivo analyses confirmed the role of GIP and the effects of the antagonist.

Indications for the Postpartum Oral Glucose Tolerance Test.

Gestational diabetes mellitus (GDM) affects more than 50 000 pregnant women in Germany every year. In postpartum diabetes screening, a 75 g oral glucose tolerance test (OGT) is recommended. This is time-consuming and can have side effects, and only 40% of mothers take it. The determination of pre-test probabilities might obviate the need for OGT except in women who are at particular risk. We analyzed 5444 cases of GDM from the GestDiab registry over the period 2015-2019. The pretest probabilities of a postpartum diagnosis of diabetes mellitus (DM) or prediabetes were calculated on the basis of clinical variables including postpartum venous fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c). In 0.77% of mothers with a history of GDM in whom DM was not detected by FPG or HbA1c, postpartum DM was diagnosed on the basis of the 2-hour value in the OGT. Individual estimation of the pre-test probability of a diagnosis by OGT of postpartum DM or prediabetes was possible with the aid of the FPG and HbA1c values and clinical predictors including insulin treatment during pregnancy, obesity, GDM diagnosed before 24 weeks of gestation, age over 35, and a 1-hour value in the diagnostic OGT during pregnancy of 180 mg/dL (10.0 mmol/L) or above. The pretest probability of postpartum DM in the study group ranged from 0.11% to 4.17%, and that of postpartum prediabetes from 6.4% to 16.3%. The probability of a diagnosis of postpartum diabetes by OGT after GDM can be estimated in postpartum screening on the basis of various parameters. This enables risk-adapted counseling of the affected women along with a long-term strategy for diabetes prevention and follow-up. The findings of our study should be verified by further research.

Carbohydrate Intake and Oral Glucose Tolerance Test Results in the Postpartum Period.

The American Diabetes Association (ADA) recommends a 3-day preparatory diet prior to a diagnostic oral glucose tolerance test (OGTT), a test often recommended in postpartum individuals with a history of gestational diabetes (GDM). Evaluate the relationship between carbohydrate intake and OGTT glucose in 2 cohorts of postpartum individuals. We performed analyses of postpartum individuals from 2 prospective studies with recent GDM (Balance after Baby Intervention, BABI, n = 177) or risk factors for GDM (Study of Pregnancy Regulation of INsulin and Glucose, SPRING, n = 104) .We measured carbohydrate intake using 24-hour dietary recalls (SPRING) or Food Frequency Questionnaire (BABI) and performed 2-hour 75-g OGTTs. The main outcome measure was 120-minute post-OGTT glucose. There was no relationship between carbohydrate intake and 120-minute post-OGTT glucose level in either study population (SPRING: β = 0.03, [-5.5, 5.5] mg/dL, P = .99; BABI: β = -3.1, [-9.5, 3.4] mg/dL, P = .35). Adding breastfeeding status to the model did not change results (SPRING β = -0.14, [-5.7, 5.5] mg/dL, P = .95; BABI β = -3.9, [-10.4, 2.7] mg/dL, P = .25). There was, however, an inverse relationship between glycemic index and 120-minute post OGTT glucose (BABI: β = -1.1, [-2.2, -0.03] mg/dL, P = .04). Carbohydrate intake is not associated with post-OGTT glucose levels among postpartum individuals. Dietary preparation prior to the OGTT may not be necessary in this population.

Association of History of Spontaneous or Induced Abortion With Subsequent Risk of Gestational Diabetes

Gestational diabetes (GD) is one of the most common and important complications of pregnancy. Identifying pregnant women who are at high risk of GD is crucial for implementing early prevention and intervention. To examine whether a history of spontaneous abortion (SAB) or induced abortion is associated with increased risk of GD in subsequent pregnancies. This retrospective cohort study was conducted at a tertiary hospital in Shanghai, China. Pregnant women who received routine antenatal care between January 2014 and December 2019 were included. Data analysis was performed from December 2020 to June 2021. Maternal history of abortion, including SAB and induced abortion, were extracted from medical records. GD was diagnosed with a 75-g diagnostic oral glucose tolerance test. A multivariable-adjusted log-binomial analysis was used to estimate relative risks (RRs) and 95% CIs of GD associated with history of abortion. Among the 102 259 included pregnant women (mean [SD] age, 29.8 [3.8] years), 14 579 (14.3%) experienced only SAB, 17 935 (17.5%) experienced only induced abortion, and 4017 (3.9%) experienced both SAB and induced abortion. A total of 12 153 GD cases were identified, and the prevalence of GD was 11.9% (12 153 of 102 259 women) in this cohort. Pregnant women who experienced only SAB (RR, 1.25; 95% CI, 1.18-1.31) or both SAB and induced abortion (RR, 1.15; 95% CI, 1.05-1.27) were at higher risk of developing GD. The association of SAB history with GD occurred in a number-dependent manner. Compared with pregnant women with no history of abortion, the RR for GD increased by 18% (RR, 1.18; 95% CI, 1.11-1.26) for pregnant women with 1 SAB, by 41% (RR, 1.41; 95% CI, 1.27-1.57) for those with 2 SABs, and by 43% (RR, 1.43; 95% CI, 1.22-1.67) for those more than 2 SABs. However, no association between history of induced abortion and GD was observed. This study found that a history of SAB was associated with increased risk of GD in subsequent pregnancies. Further research is needed to clarify this association and explore the potential biological mechanisms underlying the association.

Perinatal Outcomes in Obese Women with One Abnormal Value on 3-Hour Oral Glucose Tolerance Test.

This study aimed to determine if one abnormal value of four on the diagnostic 3-hour oral glucose tolerance test (OGTT) is associated with adverse perinatal outcomes in obese women. This is a secondary analysis of a prospective study of nulliparous women in eight geographic regions. Women with body mass index <30 kg/m2 and pregestational diabetes mellitus (GDM) were excluded. Four groups were compared: (1) normal 50-g 1-hour glucose screen, (2) elevated 1-hour glucose screen with normal 100-g 3-hour diagnostic OGTT, (3) elevated 1-hour glucose screen and one of four abnormal values on 3-hour OGTT, and (4) GDM. Using multivariable logistic regression adjusting for covariates, the women in the groups with dysglycemia were compared with those in the normal screen group for maternal and neonatal outcomes. Among 1,713 obese women, 1,418 (82.8%) had a normal 1-hour glucose screen, 125 (7.3%) had a normal 3-hour diagnostic OGTT, 72 (4.2%) had one abnormal value on their diagnostic OGTT, and 98 (5.7%) were diagnosed with GDM. The one abnormal value group had increased risk of large for gestational age (LGA) neonates (adjusted odds ratio [aOR] = 2.24, 95% confidence interval [CI]: 1.31-3.82), cesarean delivery (aOR = 2.19, 95% CI: 1.34-3.58), and hypertensive disorders of pregnancy (aOR = 2.19, 95% CI: 1.32-3.63) compared with normal screens. The one abnormal value group also had an increased risk of preterm birth <37 weeks (aOR = 2.63, 95% CI: 1.43-4.84), neonatal respiratory support (aOR = 2.38, 95% CI: 1.23-4.60), and neonatal hyperbilirubinemia (aOR = 2.00, 95% CI: 1.08-3.71). There was no association between one abnormal value with shoulder dystocia and neonatal hypoglycemia. For obese women, one abnormal value on the 3-hour OGTT confers increased perinatal adverse outcomes. These women should be studied further to determine if nutrition counseling and closer fetal monitoring improve outcomes even in the absence of a diagnosis of GDM. · Study of obese women with one abnormal value on OGTT.. · Adverse maternal and neonatal outcomes were found, including more LGA neonates.. · Neonates were not at increased risk of hypoglycemia..

Association between number of abnormal glucose values and severity of fasting plasma glucose in IADPSG criteria and maternal outcomes in women with gestational diabetes mellitus.

The International Association for Diabetes in Pregnancy Study Group (IADPSG) criteria recommend a single-step diagnostic oral glucose tolerance test (OGTT) for diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to examine the association between the number of abnormal glucose values and levels of FPG with pregnancy outcomes. Pregnant women (n=1,044) were screened for GDM at maternity centers in South India using IADPSG criteria. OGTTs were classified based on the number of abnormal glucose values (any one value or more than one value high) and fasting plasma glucose (FPG) values (<92mg/dl,92-100mg/dl,>100mg/dl) and correlated with pregnancy outcomes. Odds ratio were adjusted for age, BMI, gestational week at diagnosis, family history of diabetes, previous history of GDM, gestational week at delivery and birth weight. For macrosomia and large for gestation age, birth weight was excluded from the model. Risk of caesarean section was significantly higher in women with any one abnormal glucose value (OR: 1.49; 95%CI: 1.07-2.09). This further increased in those with >1 value (OR: 1.35; 95%CI: 0.87-2.10), when compared to women with all values normal. Risk of large for gestation age (LGA) was higher in women with FPG 92-100mg/dl (OR: 1.37; 95%CI: 0.80-2.35) and in those with FPG >100mg/dl (OR: 1.87; 95%CI: 1.04-3.35), compared to those with FPG <92mg/dl. The risk for poor pregnancy outcomes starts in those with one abnormal value in the OGTT or with FPG >92mg/dl but becomes significantly higher in those with higher abnormal values.

Characteristics of gestational diabetes subtypes classified by oral glucose tolerance test values.

BackgroundIn clinical practice, gestational diabetes mellitus (GDM) is treated as a homogenous disease but emerging evidence suggests that the diagnosis of GDM possibly comprises different metabolic entities. In this study, we aimed to assess early pregnancy characteristics of gestational diabetes mellitus entities classified according to the presence of fasting and/or post‐load hyperglycaemia in the diagnostic oral glucose tolerance test performed at mid‐gestation.MethodsIn this prospective cohort study, 1087 pregnant women received a broad risk evaluation and laboratory examination at early gestation and were later classified as normal glucose tolerant (NGT), as having isolated fasting hyperglycaemia (GDM‐IFH), isolated post‐load hyperglycaemia (GDM‐IPH) or combined hyperglycaemia (GDM‐CH) according to oral glucose tolerance test results. Participants were followed up until delivery to assess data on pharmacotherapy and pregnancy outcomes.ResultsWomen affected by elevated fasting and post‐load glucose concentrations (GDM‐CH) showed adverse metabolic profiles already at beginning of pregnancy including a higher degree of insulin resistance as compared to women with normal glucose tolerance and those with isolated defects (especially GDM‐IPH). The GDM‐IPH subgroup had lower body mass index at early gestation and required glucose‐lowering medications less often (28.9%) as compared to GDM‐IFH (47.8%, P = .019) and GDM‐CH (54.5%, P = .005). No differences were observed in pregnancy outcome data.ConclusionsWomen with fasting hyperglycaemia, especially those with combined hyperglycaemia, showed an unfavourable metabolic phenotype already at early gestation. Therefore, categorization based on abnormal oral glucose tolerance test values provides a practicable basis for clinical risk stratification.

Celiac Disease and Pregnancy Outcomes in Patients with Gestational Diabetes Mellitus.

Aim Gestational diabetes mellitus (GDM) and celiac disease, if not diagnosed and properly treated, are associated with adverse outcomes of pregnancy. The aim of our study was to examine pregnancies complicated by GDM in celiac and nonceliac women in terms of their metabolic parameters and maternal and fetal outcomes. Methods The study involved 60 women with GDM, 20 with and 40 without celiac disease. Maternal clinical and metabolic parameters (glucose and insulin levels in the oral glucose tolerance test (OGTT), fasting plasma glucose, HbA1c, lipid profile, prepregnancy BMI, gestational weight gain, and chronic diseases), pregnancy outcomes (gestational hypertension, pre-eclampsia, eclampsia, time, and mode of delivery), and fetal parameters (weight and length at birth, and neonatal complications) were recorded. Results The two groups did not differ significantly in maternal parameters other than blood glucose levels at 120′ in the diagnostic OGTT (141.2 ± 35.2 vs 161.2 ± 35.4, mg/dl, p=0.047), prepartum cLDL (127.2 ± 43.5 vs 179.6 ± 31.7 mg/dl, p ≤ 0.001), and total cholesterol (229.0 ± 45.9 vs 292.5 ± 42.1 mg/dl, p ≤ 0.001), which were significantly lower in celiac women than in nonceliac controls. Children born from celiac women had a significantly higher birth weight (3458.1 ± 409.8 vs 3209.0 ± 432.7 g, p=0.044) and ponderal index (2.89 ± 0.32 vs 2.66 ± 0.25 g/cm3, p=0.006) and were more likely to be large for gestational age (27.8% vs 2.5%, p=0.012). Analyzing the composition of the celiac and nonceliac women's diet showed that, for the same amount of kilocalories, the gluten-free diet was associated with a slight increase in the amount of carbohydrates (49.75% vs 48.54%) and a reduction in the amount of protein (21.10% vs 23.31%) and especially of fiber (9.84% vs 12.71%). Conclusions Celiac women with GDM have much the same pregnancy outcomes as nonceliac women with GDM, except for fetal overgrowth. Gluten-free food, being richer in carbohydrates and less rich in fiber and protein, could have a role in fetal growth in celiac women.

Continuing Challenges in The Medical Management of Gestational Diabetes Mellitus

The management of gestational diabetes mellitus (GDM) involves screening (or universal testing), a diagnostic oral glucose tolerance test, patient counselling/education, gestational weight management and medical nutrition therapy, and self-monitoring of blood glucose levels with regular glycaemia reviews. This is in addition to pharmacological treatment, often insulin therapy, if glycaemia is above target. Females with GDM receive more frequent ultrasound testing to assess fetal growth, and birth is planned and not usually allowed to go much past term. A range of challenges continue to arise in GDM management including screening approaches and diagnostic criteria, dealing with the increasing numbers of females diagnosed, weight and glycaemic targets, the long-term safety of oral antihyperglycaemic agents for the offspring, particularly metformin, and adjunct medication for complication prevention. GDM management involves additional complexities including differentiating between those with likely undiagnosed Type 2 diabetes mellitus (diabetes in pregnancy), how to manage females with high glucose early in pregnancy less than diabetes in pregnancy, and identifying females with rare causes, for example monogenic diabetes or new Type 1 diabetes mellitus in pregnancy. While the management of GDM has evolved from identifying females at high risk of progressing to Type 2 diabetes mellitus, to greater focus on improving pregnancy outcomes, females with prior GDM and their offspring have the highest need for follow-up and prevention strategies. To date, follow-up and intervention remains limited for this high-risk group for both diabetes and cardiovascular disease. Follow-up in these females is particularly important for the next pregnancy, especially as GDM prevention from the second trimester onwards remains another continuing challenge.

Gestational diabetes: A link between OGTT, maternal-fetal outcomes and maternal glucose tolerance after childbirth

Background and aimThe relationship among distribution of pathological values at the Oral Glucose Tolerance Test (OGTT), metabolic risk factors and pregnancy outcomes in women with Gestational Diabetes (GDM), has not been clearly identified. We retrospectively compared metabolic and therapeutic parameters, maternal–fetal outcomes and post-partum OGTTs, with respect to the number and distribution of altered values of diagnostic OGTT in pregnancy. Secondly, we assessed whether insulin therapy predictive factors were identifiable. Methods and resultsThis analysis included 602 pregnant women with GDM, followed in Diabetes and Pregnancy Unit of Perugia Hospital from diagnosis to childbirth. All women were diagnosed diabetic upon 75g OGTT, according IADPSG criteria. Women were divided into 3 groups, respect to distribution of diagnostic blood glucose (BG) values at OGTT: Group 1: only fasting BG (OGTT0h); Group 2: 1 and/or 2h (OGTT1-2h); Group 3: both fasting and 1 h and/or 2h (OGTT0+1–2h) BG.Pregnant women with fasting hyperglycemia at OGTT (Groups 1 and 3) had similar metabolic characteristics (weight, prevalence of obesity, gestational weight gain, HbA1c), a greater need for insulin therapy, and a higher risk of impaired glucose tolerance persistence after childbirth, as compared to Group 2. No significant differences were observed in terms of maternal and neonatal outcomes (p > 0.05), except for a greater prevalence of caesarean sections in Group 3. ConclusionThe metabolic characteristics of GDM women are mirrored by OGTT values at diagnosis, but are not associated with adverse pregnancy outcomes. Intensive management and a tailored treatment of GDM improve maternal-neonatal outcomes, regardless of diagnostic values distribution and pre-gestational metabolic characteristics.

Does the 1-step method of gestational diabetes mellitus screening improve pregnancy outcomes?

Despite considerate debate, the best method of diagnosing gestational diabetes mellitus remains unknown. A commonly used method of gestational diabetes mellitus screening in the United States is the 2-step method, which includes screening with a 50-gram, 1-hour glucose challenge followed by a 100-gram, 3-hour diagnostic oral glucose tolerance test. The International Association of Diabetes and Pregnancy Study Group has recommended the 1-step method using a 75-gram, 2-hour oral glucose tolerance test. The International Association of Diabetes and Pregnancy Study Group thresholds have been predicted to increase the rates of gestational diabetes mellitus, yet little is known about the effect on pregnancy outcomes, especially in the United States. This study aimed to determine whether adoption of the 1-step method of gestational diabetes mellitus screening leads to improved obstetrical outcomes at a single academic institution. This is a retrospective cohort study of patients who delivered before and after a switch from the 2-step method to the 1-step International Association of Diabetes and Pregnancy Study Group method in July 2015. Women with a due date of January 1, 2012 through October 1, 2015 were diagnosed with gestational diabetes mellitus using the 2-step method with Carpenter and Coustan criteria. After a 6-month transition period, outcomes from women with a due date of May 1, 2016 through February 1, 2018, when the 1-step International Association of Diabetes and Pregnancy Study Group criteria were used to diagnose gestational diabetes mellitus, were evaluated. Women with gestational diabetes mellitus were managed similarly throughout the study period. The primary outcome was the incidence of primary cesarean delivery. Maternal and neonatal outcomes were compared using chi-square and t tests, and multivariable logistic regression was used to control for changes in the population. With the adoption of the International Association of Diabetes and Pregnancy Study Group method, the rates of gestational diabetes mellitus more than doubled, to 23.3% from 9.2% (P<.001). The rates of primary cesarean delivery increased with the International Association of Diabetes and Pregnancy Study Group criteria (22.2% vs 19.4%, P=.001), and the incidence of shoulder dystocia was not significantly different (1.1% vs 0.8%, P=.07). The rate of preeclampsia decreased during the time the 1-step method was in use (8.2% vs 10.9%, P<.001). The rate of macrosomia was not different using a definition of ≥4500 g (0.99% vs 0.86%, P=.5) but was reduced when using a definition of ≥4000 g (8.0% vs 6.0%, P<.001). The rate of neonatal intensive care unit admission did not change significantly. Controlling for maternal age, body mass index, race or ethnicity, chronic hypertension, and parity, the adjusted odds of a diagnosis of gestational diabetes mellitus increased 3-fold (adjusted odds ratio, 3.3; 95% confidence interval, 2.90-3.66) with 1-step testing, the adjusted odds of a shoulder dystocia increased (adjusted odds ratio, 1.48; 95% confidence interval, 0.97-2.25), and the adjusted odds of preeclampsia decreased (adjusted odds ratio, 0.64; 95% confidence interval, 0.55-0.74). There was no change in the adjusted odds of primary cesarean delivery (adjusted odds ratio, 1.05; 95% confidence interval, 0.94-1.17). Although the rates of gestational diabetes mellitus increased 3-fold with the adoption of the International Association of Diabetes and Pregnancy Study Group method, the rates of primary cesarean delivery, shoulder dystocia, and birthweight ≥4500 g did not decrease in our population. The incidence of preeclampsia decreased; our analysis suggests that this was not because of the increased diagnosis of gestational diabetes mellitus. In our patient population, a large increase in the rates of gestational diabetes mellitus did not lead to an improvement in several clinically meaningful obstetrical outcomes.

188-OR: Assessing the Validity of Diagnosis Codes for Gestational Diabetes Ascertainment

Background: Researchers often rely on diagnosis codes from billing/administrative data to ascertain diagnoses, including gestational diabetes (GDM). We assessed the validity of relying on these diagnosis codes for GDM ascertainment, using laboratory criteria for GDM as the reference. Methods: We studied women seen at our hospital for prenatal care between 1998-2016. Women underwent GDM screening using a 50-gram glucose loading test (GLT) followed by a diagnostic 100-gram 3-hour oral glucose tolerance test (GTT) if the GLT result was ≥140 mg/dl. We defined GDM using National Diabetes Data Group (NDDG) criteria, which was in clinical use during the study period. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for ICD code-based ascertainment of GDM using codes for GDM (ICD-9: 648.8; ICD-10: O24.4) recorded in administrative data from inpatient and outpatient encounters. In a sensitivity analysis we included additional codes that broadly represent diabetes and abnormal glucose diagnoses (ICD-9: 249, 250, 648.0, 790.2; ICD-10: O24.0-3, O24.8-9, E08-E13, R73.0, R73.9). In a secondary analysis, we defined GDM using Carpenter-Coustan (CC) criteria. Results: Out of 49195 pregnancies, 1258 (2.6%) met NDDG criteria and 2039 (4.1%) met CC criteria based on GLT and GTT values. In the same cohort, 589 (1.2%) had GDM ICD-9/10 codes. Using NDDG criteria as the reference, we observed sensitivity of 35.2% and specificity of 99.7% for these codes. This resulted in a PPV of 75.2% and an NPV of 98.3%. In our sensitivity analysis, 700 (1.4%) pregnancies had at least one of the codes on the expanded list. The sensitivity (37.4%) and specificity (99.5%) of this set of codes was similar to the more restricted set. Results were similar for GDM defined by CC criteria. Conclusion: Using diagnosis codes from administrative data to ascertain GDM resulted in underestimation of cases. One in 4 cases identified by these codes could not be confirmed with laboratory data. Disclosure S. Hsu: None. K. Mathieu: None. A. Kaimal: None. R. Thadhani: None. K. James: None. C.E. Powe: None. Funding Massachusetts General Hospital

SUN-631 New Therapeutic Targets for Gestational Diabetes Control Impact Insulinization, Birth Weight and Neonatal Morbidities

Uncontrolled Gestational Diabetes (GD) is associated with fetal macrosomia and neonatal morbidities. New therapeutic targets for glycemic control in GD were implemented in Portugal, in January 2017 (old targets: fasting blood glucose <92 mg/dL, 1 hour after a meal <120 mg/dL; new targets: fasting blood glucose <95 mg/dL, 1 hour after a meal <140 mg/dL). (1)Our goal was to analyze the impact that these new therapeutic targets had in the insulinization degree of the pregnant woman and in the birth weight and morbidities of the newborn.We did a retrospective study with 477 pregnant women with GD followed in a specialized appointment of our Hospital, between January 2016 and December 2017.The data collected were: age, body mass index (BMI), previous abortions, previous parity, previous pregnancies, diagnostic fasting blood glucose, diagnostic oral glucose tolerance test, insulin therapy, year of birth, birth weight, neonatal morbidities and necessity of admission in the Neonatal Care Unit (NCU).We assisted 219 pregnant women in 2016 and in the following year 248, with no differences between both groups in what concerns age, BMI, parity, abortions, previous pregnancies and glycemic values at diagnosis.In 2016, 119 pregnant women were treated with insulin, while in 2017 we initiated insulin in 84 women (p<0.001). There was a strong correlation between the year and degree of insulinization (p<0.01; Lambda 0.13, p=0.03; Phi=-0.21; p<0.01).There was no difference between the median of the birth weight in 2016 and 2017 (3200 gr (P25: 2872.50; P75: 3500.00) and 3220 gr (P25: 2970.00; P75: 3525.00), respectively (p=0.34)).According to Fenton curves, 81.5% from the 2016 newborns were classified as appropriate for gestational age, 14.4% as small for gestational age and 4.2% as large for gestational age (p<0.001). In 2017, 87.0% were appropriate, 9.0% small and 4.1% large (p<0.001). This differences strongly correlate with the degree of insulinization (p=0.046; V de Cramer=0.13, p=0.03; Lambda=0.03, p=0.04).In 2016, 26.0% of the newborns had neonatal morbidities (52.7% had hypoglycemia, 28.0% had hyperbilirrubinemia, 7.0% had respiratory distress syndrome), 24.6% of them with admission in the NCU. In 2017, 19.8% of the newborns had neonatal morbidities (46.9% with hypoglycemia, 26.5% with hyperbilirrubinemia, 4.1% with respiratory distress syndrome), 34.7% of them with admission in the NCU. All of these differences were statically significant (p<0.001).In conclusion, these new targets for glycemic control in GD led to less insulinization of the pregnant women, no differences between weight at birth of the newborns, a different distribution of the weight of birth according to Fenton curves (more newborns classified as appropriate for gestational age and less classified as small or large) and a reduction of neonatal morbidities.Ref: (1) Almeida et al. Revista Portuguesa de Diabetes. 2017; 12 (1): 24-38

Positivity thresholds of HbA1c assay as a screening test for diabetes mellitus in the first trimester in high-risk populations

Objective Both gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) are associated with increased risks of preeclampsia, macrosomia, shoulder dystocia, and irreversible brachial plexus injury (BPI). Compared to the conventional second trimester oral glucose tolerance test (OGTT), screening with the HbA1c assay in the first trimester with a diagnostic second trimester OGTT has been shown to diagnose more cases of T2DM and GDM earlier. Our study examined the effect of treatment based on varied positivity thresholds in high-risk pregnancies. Study design A decision analysis model was created using TreeAge 2016 software to compare the outcomes of screening with an HbA1C in the first trimester verses no first trimester screening, with positivity thresholds ranging from 5.9 to 6.4%. Outcomes examined included neonatal mortality, preeclampsia, preterm delivery, cerebral palsy, macrosomia, permanent BPI, cost, and quality adjusted life years (QALYs) of the mother and neonate. Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. Univariate analyses were used to investigate the impact of screening positivity. Results First trimester screening was not cost-effective with an incremental cost effectiveness ratio of 5.87 when compared to screening with a positivity threshold of 6.4%. In a theoretical cohort of one million pregnancies, a screening threshold of 5.9% was the most cost-effective strategy. This strategy resulted in 2.999 million more QALYs, one less neonatal death, 346 fewer cases of preeclampsia, 66 less preterm deliveries, one less instance of cerebral palsy, and 615 fewer cases of macrosomia with nine less PBI cases. The 5.9% threshold provided an overall cost savings of $29.72 million. Conclusions Screening for diabetes in high risk pregnancies with the HbA1c assay in the first trimester is not cost effective compared to no screening; however, if screening is preformed, 5.9% should be used as the positivity threshold for diagnosis and treatment. Brief rationale With the increasing prevalence of diabetes mellitus among high-risk women in the USA, screening during pregnancy has become more important than ever. As a laboratory test, the HbA1c is relatively simple to obtain clinically, inexpensive, and its use has been well documented in the diagnosis and management of diabetes. However, there is limited data on its use in pregnancy and in particular during the first trimester. We sought to characterize the cost-effectiveness of screening with an HbA1c assay at various positivity thresholds for gestational diabetes mellitus and pre-existing type 2 diabetes in high-risk pregnancies in the first trimester. We found that this screening strategy is not cost-effective compared to no HbA1c in the first trimester and traditional oral glucose tolerance testing in the late second trimester. However, if screening is preformed, a positivity threshold of 5.9% should be used as the positivity threshold for diagnosis and treatment as it is associated with the best outcomes.

Fasting plasma glucose and risk factor assessment: Comparing sensitivity and specificity in identifying gestational diabetes in urban black African women.

Identifying women with gestational diabetes mellitus (GDM) allows interventions to improve perinatal outcomes. Afasting plasma glucose (FPG) level ≥5.1 mmol/L is 100% specific for a diagnosis of GDM. The International Association of Diabetes and Pregnancy Study Groups acknowledges that FPG &lt;4.5 mmol/L is associated with a low probability of GDM. The validity of selective screening based on the presence of risk factors was compared with the universal application of FPG ≥4.5 mmol/L to identify women with GDM. FPG ≥4.5 mmol/L or the presence of one or more risk factors was assumed to indicate an intermediate to high risk of GDM and therefore the need for an oral glucose tolerance test (OGTT). Consecutive black South African (SA) women were recruited to a 2-hour 75 g OGTT at 24 - 28 weeks' gestation in an urban community health clinic. Of 969 women recruited, 666 underwent an OGTT, and of these 589 were eligible for analysis. The glucose oxidase laboratory method was used to measure plasma glucose concentrations. The World Health Organization GDM diagnostic criteria were applied. All participants underwent a risk factor assessment. The χ2 test was used to determine associations between risk factors and a positive diagnosis of GDM. The sensitivity and specificity of a positive diagnosis of GDM were calculated for FPG ≥4.5mmol/L, FPG ≥5.1 mmol/L, and the presence of one or more risk factors. The prevalence of overt diabetes mellitus and GDM was 0.5% and 7.0%, respectively. Risk factor-based selective screening indicated that 204/589 (34.6%) of participants needed an OGTT, but 18/41 (43.9%) of positive GDM diagnoses were missed. Universal screening using the FPG threshold of ≥4.5 mmol/L indicated that 152/589 (25.8%) of participants needed an OGTT, and 1/41 (2.4%) of positive diagnoses were missed. An FPG of ≥5.1 mmol/L identified 36/41 (87.8%) of GDM-positive participants. The sensitivity and specificity of the presence of one or more risk factors were 56% and 67%, respectively. The sensitivity and specificity of FPG ≥4.5 mmol/L were 98% and 80%, respectively. Universal screening using FPG ≥4.5 mmol/L had greater sensitivity and specificity in identifying GDM-affected women and required fewer women to undergo a resource-intensive diagnostic OGTT than risk factor-based selective screening. A universal screening strategy using FPG ≥4.5 mmol/L may be more efficient and cost-effective than risk factor-based selective screening for GDM in black SA women.

Intervention to Reduce Unnecessary Glucose Tolerance Testing in Pregnant Women.

Gestational diabetes mellitus (GDM) can be diagnosed in pregnant women by increased fasting plasma glucose alone, which eliminates the need for performing a 75 g oral glucose tolerance test (OGTT). If whole blood glucose meters are used to triage fasting samples in order to decide whether to give the glucose drink, a cutpoint with appropriate sensitivity and specificity for elevated fasting plasma glucose is needed. The number of GDM diagnoses by increased fasting plasma glucose alone was determined from specimens collected and tested at core laboratories in urban hospitals, rural health centers, and from specimens collected at patient phlebotomy service centers (PSCs) for plasma testing at a central laboratory. The number of glucose drinks avoided was counted after implementing the diagnostic cutoff of ≥95 mg/dL (5.3 mmol/L) at urban hospitals and rural health centers, which have on-site plasma testing, and after selecting a PSC meter fasting venous whole blood glucose cutpoint after calculating sensitivity and specificity for plasma glucose ≥95 mg/dL (5.3 mmol/L) using logistic regression. Among 4850 OGTTs, there were 1315 GDM diagnoses annually, of which 409 were from increased fasting plasma glucose. Ninety-one percent of OGTTs were performed at PSCs. If a fasting plasma glucose cutpoint of ≥95 mg/dL (5.3 mmol/L) was implemented at urban hospitals and rural health centers and a meter fasting venous whole blood glucose cutpoint of ≥108 mg/dL (6.0 mmol/L) (25% sensitivity, 99.9% specificity) was implemented at PSCs, the drink would be appropriately avoided by 145 patients/year, and inappropriately avoided by 3 patients/year. After implementing these cutpoints, the drink was appropriately avoided in 91 patients during a 36-week period, with none inappropriately avoiding it. Modifying fasting glucose cutpoints reduced unnecessary diagnostic OGTTs in pregnant women.

Inflammatory and related biomarkers are associated with post-transplant diabetes mellitus in kidney recipients: a retrospective study.

In this study, we investigate the association between selected inflammatory-related biomarkers and post-transplant hyperglycemia in kidney transplant recipients. This retrospective analysis comprises 852 patients receiving a kidney transplant at the Norwegian national transplant center between 2007 and 2012, all having a normal oral glucose tolerance test (OGTT) before transplantation. A diagnostic OGTT was performed 10weeks post-transplant to examine the association between inflammation-related biomarkers and two-hour plasma glucose (2HPG) by multivariable linear regression models adjusting for BMI, age, graft function, fasting insulin levels, dosage of prednisolone, and concentration of calcineurin inhibitors. Six of 20 biomarkers were significantly associated with 2HPG in multivariate analyses showing strong associations with soluble tumor necrosis factor type 1 (P=0.027), Pentraxin 3 (P=0.019), macrophage migration inhibitory factor (P=0.024), and endothelial protein C receptor (P=0.001). These associated markers reflect several distinct but also overlapping pathways including activation of tumor necrosis factor, macrophages, and endothelial cells. The multinomial logistic regression model showed a clear association between the inflammatory biomarkers and post-transplant diabetes mellitus (PTDM). The association between a range of inflammation markers and PTDM suggests that these markers may be target for future studies on pathogenesis and perhaps also treatment of PTDM.

Risk factors associated with the development of postpartum diabetes in Japanese women with gestational diabetes

BackgroundAlthough the onset of gestational diabetes (GDM) is known to be a significant risk factor for the future development of type 2 diabetes, this risk specifically in women with GDM diagnosed by the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria has not yet been thoroughly investigated. This study was performed to investigate the risk factors associated with the development of postpartum diabetes in Japanese women with a history of GDM, and the effects of the differences in the previous Japanese criteria and the IADPSG criteria.MethodsThis retrospective cohort study included Japanese women with GDM who underwent at least one postpartum oral glucose tolerance test (OGTT) between 2003 and 2014. Cases with overt diabetes in pregnancy were excluded. We investigated the risk factors including maternal baseline and pregnancy characteristics associated with the development of postpartum diabetes.ResultsAmong 354 women diagnosed with GDM during the study period, 306 (86%) (116/136 [85.3%] and 190/218 [87.2%] under the previous criteria and the IADPSG criteria, respectively) who underwent at least 1 follow-up OGTT were included in the study. Thirty-two women (10.1%) developed diabetes within a median follow-up period of 57 weeks (range, 6–292 weeks). Eleven (9.5%) and 21 (11.1%) were diagnosed as GDM during pregnancy based on the previous Japanese criteria and the IADPSG criteria, respectively, which did not significantly differ between those criteria. A multivariate logistic regression analysis revealed that HbA1c and 2-h plasma glucose (PG) at the time of the diagnostic OGTT during pregnancy were independent predictors of the development of diabetes after adjusting for confounders. The adjusted relative risk of HbA1c ≥5.6% for the development of diabetes was 4.67 (95% confidence interval, 1.53-16.73), while that of 2-h PG ≥183 mg/dl was 7.02 (2.51-20.72).ConclusionsA modest elevation of the HbA1c and 2-h PG values at the time of the diagnosis of GDM during pregnancy are independent predictors of the development of diabetes during the postpartum period in Japanese women with a history of GDM. The diagnostic criteria did not affect the incidence of postpartum diabetes.

975: Early pregnancy hemoglobin a1c screening for overt diabetes among at-risk women

Early, accurate identification of pregnant women with overt but undiagnosed type 2 diabetes (T2DM) would allow for timely treatment. Our objective was to assess the association between early pregnancy hemoglobin A1c (A1c) and oral glucose tolerance test (OGTT) results to identify overt T2DM in at-risk women. Retrospective cohort study of pregnant women at risk for T2DM who underwent A1c and OGTT screening < 21 weeks’ gestation. We defined ‘at-risk’ as women with a singleton gestation and a prior history of GDM or pre/early pregnancy BMI ≥ 30 kg/m2. We excluded women with pre-existing T2DM, an A1c ≥6.5%, or hematocrit <27 mg/dL. We compared median A1c levels in women with and without abnormal diabetes screening (1-h OGTT ≥135 mg/dL) and T2DM diagnostic testing (3-h OGTT using Carpenter-Coustan criteria, or persistent fasting capillary blood glucose ≥ 95 mg/dL and/or 1-h postprandial ≥140 mg/dL) using Mann-Whitney U test. ROC curves correlated A1c to screening and diagnostic OGTT results. Sensitivity, specificity, PPV, NPV, and diagnostic odds ratio (DOR) were calculated for A1c thresholds identified by ROC curves. 229 women were included. A1c was measured at a median (IQR) of 10.1 weeks (8.6, 13.6) with a median (IQR) level of 5.3% (5.1, 5.5). 1-h OGTTs were completed at a median (IQR) GA of 13.9 weeks (12.0, 16.7) with a median (IQR) level of 109 mg/dL (93, 132). 51 (22.5 %) of 227 women had abnormal 1-h OGTTs. 18 (7.9%) of 227 had abnormal diagnostic testing. Median (IQR) A1c levels were higher in women with an abnormal versus normal 1-h OGTT [5.5% (5.3, 5.8) versus 5.3% (5.1, 5.5), p<0.001)]. Median (IQR) A1c was also higher in women diagnosed with T2DM compared to those without T2DM [5.8% (5.4, 6.0) versus 5.3% (5.1, 5.5), p<0.001]. ROC curves are shown in the Figure. The AUC for A1c of > 5.6% to detect T2DM by positive 3-h OGTT was 0.73. Sensitivity, specificity, PPV, NPV, and DOR for different A1c thresholds are shown in the Table. Early in pregnancy, 1-h OGTT followed by 3-h OGTT is the gold standard to identify overt T2DM. For women unwilling or unable to undergo OGTT, an A1c threshold of 5.6 provides fair diagnostic accuracy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk Factors for Gestational Diabetes Mellitus

Objective: The present study was undertaken to determine the risk factors for Gestational Diabetes Mellitus (GDM) presented at Bangladesh Institute of Research in Diabetes, Endocrine &amp; Metabolic Disorders (BIRDEM).&#x0D; Materials &amp; methods: The present case-control study was conducted at BIRDEM Hospital, Dhaka over a period of 6 months from July to December 2011. A total of 100 pregnant women (20 cases and 80 controls) were consecutively enrolled in the study. Pregnant women who developed diabetes at their 3rd trimester were cases (n = 20), while pregnant women free from diabetes at their 3rd trimester were controls (n = 80). The diagnosis of GDM was made using a two-step approach. Pregnant women were initially screened by measuring the plasma glucose concentrations 1 hour after a 50 gram of oral glucose challenge. A diagnostic oral glucose tolerance test was performed on the subset of women whose plasma glucose concentrations exceded the threshold value for glucose (&gt; 140 mg/dl).&#x0D; Result: The study showed that older patients (≥ 25 years) were predominant in both case and control groups. The groups were almost comparable in terms of socioeconomic status and occupation. The distribution of gestational age was also similar between groups (33.1 ± 6.3 vs. 34.2 ± 3.9 years, p = 0.476). Majority (85%) of the cases had family history of diabetes (p &lt; 0.001). Thirty five percent of cases were nulipara and 65% multipara compared to 51.3% and 48.7% respectively of the control (p = 0.076). No significant difference was observed between the groups in terms of preterm labour and PROM (p = 0.690 and 0.220 respectively). Forty percent of cases had past history of GDM compared to 3.8% of controls (p &lt; 0.001). The fasting plasma glucose and plasma glucose 2 hrs after 75 g of glucose ingestion were significantly higher in pregnant women having GDM than those in normal pregnant women (8.3 ± 3.1 vs. 4.1 ± 0.5 mmol/L, p &lt; 0.001;12.9 ± 4.8 vs. 5.9 ± 1.2 mmol/L, p &lt; 0.001 respectively).&#x0D; Conclusion: The study concluded that none of the sociodemographic characteristics like age, socioeconomic status and occupation was found to be associated with GDM. However, pregnant women with family history of diabetes are at risk of developing GDM significantly more than those without GDM. Multipara tend to develop GDM more frequently than the primipara does. Past incidence of GDM increases the risk of GDM in the subsequent pregnancy.&#x0D; Ibrahim Card Med J 2015; 5 (1&amp;2): 49-53